Understanding a person’s
challenging behaviour
A psychiatric perspective
Tony Holland
University of Cambridge
Overview
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The term challenging behaviour is a ‘descriptive’ term – it does not
imply any understanding as to the causes of such behaviour;
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A holistic approach is clearly required – that implies a bio-psychosocial model of understanding;
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Key to any successful intervention is the formulation
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Different theoretical perspectives
Importance of matching observations and data collect to theory
Interventions based on established efficacy
Where medication is used it is on the basis of a clear hypothesis
that the challenging behaviour may wholly or partly be related to
the presence of a co-morbid disorder known to respond to such
medication
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Anticonvulsants (epilepsy)
Anti-depressants and mood stabilising medications (depression, bipolar
disorder, anxiety)
Anti-psychotic medication (psychotic illness)
Treatments for physical illness, pain etc
Complexity of developmental
disabilities
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Aetiology and developmental trajectories:
Nature and extent of impairment and associated
disabilities;
Associated ‘developmental’ impairments
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Associated co-morbidities
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Personality
Autism spectrum conditions
Neurodevelopmental syndromes
Sensory
Physical health
Mental health
Past and present life circumstances
Individual differences and gene/environment interactions
Complexity of challenging
behaviour and psychiatric disorder
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Terminology
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Conceptual models
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Descriptive
Aetiological
Applied behavioural analysis
Acquired disorders (psychiatric; medical)
Developmental
Systemic factors
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Family and carer responses
‘Emotional’ environments
Matrix
Biological
 Developmental
 Psychological
 Environmental

Onset and continuation of ‘behaviour’
and/or abnormal mental state
Predispose
 Precipitate
 Maintain
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Triggering events
Wider physical and
emotional environment
Setting events
Applied behavioural
analysis
Delayed or atypical
development
Autism spectrum
conditions
Behavioural phenotypes
Co-morbidities
Physical illness
Psychiatric
illness
Sequelae of
abuse
ASSESSMENT PROCESS
DATA COLLECTION AND ORGANISATIONAL PHASE
Identification of
index problems
Data
collection
History, mental state and
physical examination from
patient and informant
For example:
Onset of new problem behaviours
Change in general well-being
Loss of skills
Deterioration in frequency/severity of
long-standing behaviours
INVESTIGATION & INTERVENTION PHASE
Final
formulation
Initial
formulation
Intervention
& evaluation
Investigations &
observations
e.g., ABC charts, psychometric
assessments, monitoring of
mental state, blood tests, scans
Differential diagnosis
Identification of possible factors
that predispose, precipitate
and/or maintain behaviours
and/or abnormal mental state.
Specific interventions
& treatments
Monitoring outcomes
Developmental psychopathology
Co-morbid diagnoses (if present)
Identified functions of behaviours
aetiological and maintaining factors
Approaches to intervention
Emerson, Hatton et al, 1998
Formulation of the problem should reflect contemporary
scientific knowledge
Empirical testing of hypotheses
Review and revision of ‘model’ in the light of data
collected
Intervention based on a) understanding of individual; b)
scientific evidence of effectiveness of proposed
intervention
Scientifically sound evaluation of outcomes
Behaviour in PWS
Population-based study
Prevalence (%) of specific behaviours (n=65)
Definite sometime
none
Excessive eating
78
21
1
Obsessional
70
23
7
Tempers
67
27
6
Skin picking
59
22
19
Mood swings
38
19
43
Mechanisms linking the genotype to the
‘PWS behavioural phenotype’
Propose that different mechanisms link genotype to
phenotype in PWS:
Eating disorder – direct effect of dysregulation of
expression of paternally expressed maternally
imprinted gene;
Repetitive and ritualistic behaviours – arrested
development – inability to switch tasks leads to
temper outbursts;
Mood disorder- shift in liability threshold in PWS
Psychotic illness excess expression paternally
imprinted maternally expressed gene
Number of people
Graph to show the number of people with at
least one psychotic symptom
(all ages 18years+)
100
90
80
70
60
50
40
30
20
10
0
No psychotic symptoms
74
Any psychotic symptom
10
12
19
Deletion
Disomy
Genetic subtype
Fishers Exact test; p<0.001
Management of CB affecting people
with PWS
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Understand the ‘mechanisms’ that underpin the
behaviour;
Different for different behaviours or mental
illnesses;
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Eating
Repetitive
Mood disorder
Effective intervention requires combining
knowledge about the individual and the
syndrome
Examples
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Mr H with ASC – increasing aggressive behaviour
over many years starting aged 13. Severe
bipolar disorder and psychotic illness – CB
resolved with treatment of his illness;
Mr R with moderate LD - arrested by the police
for indecent exposure – undressing part of a
complex partial seizure;
Ms C with mild LD and ASC – periodic
problematic behaviour mainly at times of
unexpected change when associated with severe
anxiety – various strategies including SSRI for
anxiety.